With Blue Cross Blue Shield (BCBS) covering 1 in 3 Americans, understanding their reimbursement policies for mental health services is not just a good idea—it's essential. This guide provides therapists with a comprehensive look at how BCBS pays for services, helping you to navigate billing complexities and optimize your revenue cycle management.
BCBS by the Numbers: A Quick Look
BCBS's Footprint in the U.S.
Key Statistics on BCBS Coverage
- 33+ Independent Companies: BCBS operates through more than 33 different companies across the U.S., each with its own specific policies, fee schedules, and networks.
- 1 in 3 Americans Covered: The BCBS network provides health coverage to more than 107 million people, making it a dominant force in the insurance market.
- State-Specific Policies: Since each BCBS plan is unique to its state and local market, a therapist's reimbursement rate can vary significantly from one state to another, even for the same CPT code.
These numbers highlight why it's so important for mental health professionals to understand the intricacies of BCBS reimbursement. A one-size-fits-all approach to billing will almost certainly lead to errors, delays, and lost revenue.
Understanding the Therapy Reimbursement Process
Reimbursement is the process by which you get paid after providing a therapy session. As a provider, you submit a claim to BCBS, and they, in turn, pay you based on your contract and the patient’s specific plan details. This process can be simple if done correctly, but it can quickly become complex if key steps are missed. Knowing the difference between an in-network and an out-of-network provider is one of the first and most critical steps.
Key Terms Every Provider Should Know
Billed vs. Allowed Amount
The billed amount is the total fee you charge for your services. The allowed amount is the maximum amount BCBS agrees to pay for that service, based on the patient's plan and your contract. Your reimbursement is calculated from this allowed amount.
In-network vs. Out-of-network
An in-network provider has a formal contract with BCBS, agreeing to their negotiated rates. This generally results in higher, more predictable payments. An out-of-network provider has no contract; payments are often lower, and the patient may face significantly higher out-of-pocket costs.
Deductible, Copay, and Coinsurance
The patient's out-of-pocket costs are determined by their deductible (the amount they must pay before insurance kicks in), copay (a fixed fee per visit), and coinsurance (a percentage of the allowed amount the patient pays). These amounts are subtracted from your reimbursement.
The Reimbursement Flow: A Step-by-Step Guide
The path from a patient's session to a successful reimbursement is a multi-step process. Here’s a breakdown of the typical workflow to help you visualize and streamline your own billing practices.
Patient Check-In
Verify eligibility and benefits before the first session to confirm coverage and patient responsibility.
Service Provided
Deliver the therapy session and thoroughly document all details, including diagnosis and procedure codes.
Claim Submission
Submit a clean claim to BCBS with the correct CPT, ICD-10, and modifier codes.
Claim Adjudication
BCBS reviews the claim for accuracy, medical necessity, and adherence to plan policies.
Payment & EOB
BCBS sends reimbursement to the provider and an Explanation of Benefits (EOB) to the patient.
Estimated BCBS Reimbursement Rates by CPT Code
The reimbursement you receive depends on the specific service provided, which is identified by a CPT (Current Procedural Terminology) code. These codes are standardized by the American Medical Association (AMA) and are essential for accurate billing. Below is a detailed table with estimated reimbursement ranges for some of the most common mental health CPT codes.
| Procedure | CPT Code | Estimated BCBS Reimbursement (per session) | Additional Notes |
|---|---|---|---|
| Psychiatric Diagnostic Evaluation | 90791 | $150 – $300 | Initial evaluation, often for new patients. |
| Psychotherapy, 30 minutes | 90832 | $60 – $120 | Common for shorter sessions; reimbursement varies by region. |
| Psychotherapy, 45 minutes | 90834 | $80 – $140 | Typical session length for ongoing therapy. |
| Psychotherapy, 60 minutes | 90837 | $100 – $160 | Longer sessions for more complex therapy. |
| Family Therapy (without patient) | 90846 | $90 – $150 | Therapy focused on family dynamics, no patient present. |
| Family Therapy (with patient) | 90847 | $100 – $170 | Family therapy with patient involved in the session. |
| Group Psychotherapy | 90853 | $30 – $70 | Shared therapy with multiple clients in a group setting. |
| Crisis Psychotherapy, 60 minutes | 90839 | $120 – $200 | Immediate therapy for mental health crises. |
| Add-on for Crisis Psychotherapy | 90840 | $50 – $100 | Used in addition to 90839 for extended crisis therapy. |
| Telehealth Counseling | Varies | $50 – $110 | Online therapy sessions, reimbursement varies by plan and state. |
| Psychiatric Diagnostic Evaluation (Interactive) | 90792 | $180 – $350 | Used when the evaluation is interactive with the patient. |
| Psychological Testing (Per Hour) | 96130 | $150 – $250 | Comprehensive testing for mental health conditions. |
| Neuropsychological Testing | 96136 | $250 – $400 | In-depth assessments of cognitive functions. |
| Add-on for Neuropsychological Testing | 96137 | $100 – $150 | Add-on for additional testing services. |
Disclaimer: These figures are estimates based on provider reports and claims data. Actual reimbursement rates can vary significantly based on your specific BCBS contract, geographic location, and the patient's plan details.
State-by-State BCBS Therapy Reimbursement Rates
Due to the decentralized nature of BCBS, reimbursement rates for therapy vary widely across the country. The table below provides real-world estimates for a 60-minute psychotherapy session (CPT Code 90837) to help you set realistic rates, negotiate contracts, and understand your potential revenue, especially if you offer telehealth services across state lines.
| State | In-Network Rate (USD) | Out-of-Network Rate (USD) | RxCredentialing Billers’ Notes |
|---|---|---|---|
| Alabama | $85–$95 | $70–$85 | Rates vary by region; urban areas may see higher reimbursements. |
| Alaska | $110–$125 | $90–$110 | Higher rates due to limited provider availability. |
| Arizona | $100–$115 | $80–$100 | Competitive rates; urban centers like Phoenix may offer higher reimbursements. |
| Arkansas | $80–$90 | $65–$80 | Rural areas may experience lower rates; urban centers provide higher reimbursements. |
| California | $100–$120 | $80–$100 | Significant variation; urban areas like San Francisco and Los Angeles offer higher rates. |
| Colorado | $95–$105 | $75–$95 | Rates are competitive; the Denver area may have slightly higher reimbursements. |
| Connecticut | $105–$115 | $85–$105 | Higher rates in urban areas; rural regions may see slightly lower reimbursements. |
| Delaware | $90–$100 | $70–$90 | Rates are consistent across the state. |
| Florida | $95–$105 | $75–$95 | Urban areas like Miami and Orlando offer higher reimbursements. |
| Georgia | $85–$95 | $70–$85 | Rates vary by region; metropolitan areas may have higher reimbursements. |
| Hawaii | $115–$125 | $95–$115 | Higher rates due to limited provider availability. |
| Idaho | $75–$85 | $60–$75 | Rural areas may experience lower rates; urban centers provide higher reimbursements. |
| Illinois | $100–$110 | $80–$100 | The Chicago area offers higher reimbursements; rates vary in other regions. |
| Indiana | $85–$95 | $70–$85 | Rates are consistent across the state. |
| Iowa | $80–$90 | $65–$80 | Rural areas may experience lower rates; urban centers provide higher reimbursements. |
| Kansas | $75–$85 | $60–$75 | Rates vary by region; urban areas may have higher reimbursements. |
| Kentucky | $80–$90 | $65–$80 | Rates are consistent across the state. |
| Louisiana | $85–$95 | $70–$85 | Urban areas like New Orleans offer higher reimbursements. |
| Maine | $90–$100 | $70–$90 | Rates are consistent across the state. |
| Maryland | $100–$110 | $80–$100 | Higher rates in urban areas; rural regions may see slightly lower reimbursements. |
| Massachusetts | $110–$120 | $90–$110 | Higher rates in urban areas like Boston; rural regions may see slightly lower reimbursements. |
| Michigan | $95–$105 | $75–$95 | Rates vary by region; metropolitan areas offer higher reimbursements. |
| Minnesota | $90–$100 | $70–$90 | Rates are consistent across the state. |
| Mississippi | $80–$90 | $65–$80 | Rural areas may experience lower rates; urban centers provide higher reimbursements. |
| Missouri | $85–$95 | $70–$85 | Rates vary by region; urban areas may have higher reimbursements. |
| Montana | $75–$85 | $60–$75 | Rural areas may experience lower rates; urban centers provide higher reimbursements. |
| Nebraska | $80–$90 | $65–$80 | Rates vary by region; urban areas may have higher reimbursements. |
| Nevada | $90–$100 | $70–$90 | Rates are consistent across the state. |
| New Hampshire | $95–$105 | $75–$95 | Higher rates in urban areas; rural regions may see slightly lower reimbursements. |
| New Jersey | $105–$115 | $85–$105 | Higher rates in urban areas like Newark and Jersey City; rural regions may see slightly lower reimbursements. |
| New Mexico | $85–$95 | $70–$85 | Rates vary by region; urban areas may have higher reimbursements. |
| New York | $110–$120 | $90–$110 | Significant variation; urban areas like New York City offer higher rates. |
| North Carolina | $90–$100 | $70–$90 | Rates are consistent across the state. |
| North Dakota | $75–$85 | $60–$75 | Rural areas may experience lower rates; urban centers provide higher reimbursements. |
| Ohio | $85–$95 | $70–$85 | Rates vary by region; metropolitan areas offer higher reimbursements. |
| Oklahoma | $80–$90 | $65–$80 | Rates are consistent across the state. |
| Oregon | $100–$110 | $80–$100 | Higher rates in urban areas like Portland; rural regions may see slightly lower reimbursements. |
| Pennsylvania | $95–$105 | $75–$95 | Rates vary by region; urban areas may have higher reimbursements. |
| Rhode Island | $90–$100 | $70–$90 | Rates are consistent across the state. |
| South Carolina | $85–$95 | $70–$85 | Rates vary slightly between Charleston and other metro regions. |
| South Dakota | $75–$85 | $60–$75 | Rural providers may face lower rates; limited data for urban regions. |
| Tennessee | $85–$95 | $70–$85 | Nashville providers typically receive higher rates than rural counterparts. |
| Texas | $90–$105 | $70–$90 | Rates vary significantly by city; Dallas and Austin are generally higher. |
| Utah | $85–$95 | $70–$85 | Salt Lake City rates are slightly higher; rural areas below average. |
| Vermont | $95–$105 | $75–$95 | Consistent rates across the state due to a small provider base. |
| Virginia | $95–$105 | $75–$95 | Urban areas like Northern Virginia often receive higher reimbursement. |
| Washington | $100–$110 | $80–$100 | Seattle area rates are higher; telehealth rates on par with in-person. |
| West Virginia | $80–$90 | $65–$80 | Lower end of national average; limited provider network. |
| Wisconsin | $90–$100 | $70–$90 | Metro areas such as Madison and Milwaukee pay more than rural regions. |
| Wyoming | $80–$90 | $65–$80 | Small market, but rates are stable; may be influenced by parity laws. |
Disclaimer: These are approximate figures for CPT 90837. Reimbursement can fluctuate based on local BCBS affiliates, provider contracts, and specific geographic regions within a state.
Factors Influencing BCBS Therapy Reimbursement Rates
Understanding the reimbursement rate tables is just the beginning. The actual payment you receive is the result of several intertwined factors. By considering these elements, you can better predict your revenue and make informed decisions about your practice.
Geographic Location and Cost of Living
Reimbursement rates often reflect the local cost of living. Urban areas with higher costs and greater demand for services typically offer higher rates. Conversely, rural areas may have lower rates, though some regions offer incentives to encourage providers to serve underserved populations.
BCBS Plan Type
The specific plan a patient has—such as an HMO, PPO, or HDHP—greatly influences reimbursement. PPO plans, for example, often have higher rates due to their broader network flexibility, while HMO plans may offer lower rates but with a more controlled provider network. For more information on different plan types, check out our guide to understanding health insurance plans.
Provider’s Contract Status
Being an in-network provider means you have a contract with BCBS. This ensures adherence to negotiated rates, reduces administrative hurdles, and results in more predictable payments. Out-of-network providers, on the other hand, often receive lower payouts, which can complicate your revenue cycle management.
Session Length and Complexity
Reimbursement rates are directly tied to the CPT code submitted, which reflects the duration and complexity of the session. Longer sessions (e.g., 60-minute psychotherapy, CPT 90837) or specialized services (e.g., diagnostic evaluations) warrant higher reimbursement due to the increased time and expertise required.
Legislative and Policy Factors
Changes in legislation and policy can significantly impact reimbursement. For example, changes from the Centers for Medicare & Medicaid Services (CMS) can affect all insurance plans. State-level mental health parity laws also require insurers to cover mental health services at the same level as medical care, which can influence rates.
Economic and Cost Factors
Economic indicators, such as the Medicare Economic Index (MEI), reflect the rising costs of running a practice. While reimbursement rates may not always keep pace with these increases, they do play a role in annual adjustments. Providers must be mindful of their own practice expenses when setting their fee schedules.
Telehealth and BCBS Reimbursement
The post-COVID-19 landscape has made telehealth a staple of mental health care. BCBS now routinely reimburses for virtual sessions, often at rates comparable to in-person therapy. However, these policies are not uniform across the country, making it crucial for providers to stay informed about regional differences and specific billing requirements.
How to Ensure Telehealth Claims Are Paid Correctly
To avoid denials and ensure timely payment for virtual sessions, therapists must be meticulous with their claims. Key steps include:
- Correct Coding: Use the appropriate CPT codes for the service provided. For telehealth, it's also critical to use the correct modifier, such as the GT or 95 modifier, to indicate a live audio/video session.
- Verifying Policies: Always check your state's specific telehealth parity laws and the policies of your local BCBS company. What is covered in one state may not be in another.
- Thorough Documentation: As with in-person sessions, comprehensive documentation is vital. Note the session's duration, the therapeutic interventions used, and the method of delivery (e.g., "telehealth via HIPAA-compliant platform").
- Check for In-Network Status: While many BCBS companies have expanded telehealth coverage, they may still have different reimbursement rates for in-network vs. out-of-network providers.
BCBS Plans and Their Therapy Coverage Compared
BCBS offers a wide range of plans, each with a unique structure and specific coverage for mental health services. Knowing the differences between these plan types helps you guide your patients and understand your reimbursement expectations.
| Plan Type | Network Flexibility | Therapy Coverage Highlights | Cost Considerations |
|---|---|---|---|
| PPO (Preferred Provider Organization) | High flexibility | Covers in-network and partial out-of-network therapy. | Higher premiums; lower cost-sharing in-network. |
| HMO (Health Maintenance Organization) | Restricted to network | Therapy covered in-network only; referral required. | Lower premiums; lower out-of-pocket costs. |
| EPO (Exclusive Provider Organization) | In-network only | Covers in-network therapy; no referral needed. | Similar to PPO but with no out-of-network coverage. |
| POS (Point of Service) | Moderate flexibility | Requires a PCP referral but offers some out-of-network options. | Mid-range premiums; out-of-network care costs more. |
| HDHP (High Deductible Health Plan) | Varies | Therapy covered after deductible is met; HSA funds can be used. | Low premiums, high deductible; HSA funds help pay costs. |
| Medicare Advantage | Network-based | Covers outpatient therapy and psychiatric services. | Cost-sharing varies based on the plan. |
| Medicaid Plans | Network-based | Comprehensive behavioral health coverage. | Low or no cost-sharing for eligible individuals. |
FAQs on BCBS Therapy Coverage and Reimbursements
Here are answers to some of the most common questions therapists have about billing BCBS for mental health services. This section is designed to provide quick, actionable insights into your most pressing concerns.
Yes, you must always verify patient eligibility and benefits before the first session. This is a crucial step to ensure the patient’s plan covers the service and to understand their financial responsibility. You can do this through the BCBS provider portal, by calling their provider line, or using an electronic medical billing service. This proactive step prevents claim rejections and unexpected patient bills.
To file a claim, ensure you have all the necessary information: the correct CPT code, the specific diagnosis code (ICD-10), the date of service, and any applicable modifiers. You can submit claims electronically through the BCBS provider portal or a clearinghouse. This method is faster and more reliable than mailing paper claims. Following all BCBS claim submission guidelines is essential to prevent delays.
On average, BCBS processes claims within 30 to 45 days. However, this can vary based on the complexity of the claim, whether you are in-network or out-of-network, and the specific BCBS plan. You can track the status of your claims directly through the provider portal. If a claim remains unprocessed after 30 days, it's wise to follow up.
If you receive a denial, first, carefully review the reason given in the denial notice. Then, contact the BCBS provider support line for more clarification. If you believe the denial was an error, you have the right to appeal. This process may involve submitting an appeal form and providing additional documentation to support the medical necessity of the service. For help with denials and accounts receivable, consider our AR recovery services.
Yes, BCBS generally covers a wide range of mental health services, including individual, group, and family therapy, as well as psychiatric evaluations. However, coverage details—including copays, deductibles, and any session limits—are specific to the patient's plan. Always verify these details with the patient and BCBS before beginning treatment.
To verify coverage, you can ask the patient for their Summary of Benefits, focusing on the “Outpatient Mental Health” section. You can also use the BCBS provider portal or call the member services number on the back of the patient’s insurance card. Be sure to ask about network requirements, any prior authorization needs, and the patient's remaining deductible.
Yes, BCBS widely supports telehealth for therapy services. However, it's crucial to use the correct CPT codes and modifiers (such as 95 or GT) to indicate the service was delivered via telehealth. Reimbursement rates may differ from in-person sessions, so it's important to check your local BCBS policies.
If the patient sees an out-of-network therapist, reimbursement will be at a lower rate, and the patient will be responsible for a larger portion of the cost. The provider may need to submit the claim on the patient's behalf. While PPO plans often provide some coverage for out-of-network care, HMO and EPO plans typically do not.
To minimize denials, follow these best practices: always verify eligibility, use accurate CPT and ICD-10 codes, and ensure thorough documentation of each session. Submitting claims promptly and electronically is also a key factor. For additional support, our medical billing services can help you manage your claims efficiently.
Conclusion
Navigating Blue Cross Blue Shield's reimbursement landscape for therapy can be a complex but rewarding process. By understanding the factors that influence rates, from geographic location and plan type to the specific CPT codes you use, you can take control of your practice's financial health.
The key to success lies in meticulous attention to detail: verifying patient eligibility, using accurate billing codes, and staying informed about state-specific policies. By following these best practices, you can minimize claim denials, ensure timely and accurate reimbursement, and focus on what truly matters—providing excellent care to your patients. If you're a provider in need of a partner to help with your medical billing and credentialing, visit our website to learn more about how RxCredentialing can help.
